Laserfiche WebLink
San Joaquin County Public Health S is ces <br /> ironmental Health Division, <br /> PetcaedicalWaste Management Program* <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste <br /> Management Act', you are required to meet the following conditions: <br /> 1- Your medical office/business generates less than 20 pounds of regulated medical <br /> waste per week. <br /> 2- Your medical officelbusiness transports less than 20 pounds of regulated medical <br /> waste at any one time. <br /> 3- Your medical officelbusiness maintains records of any regulated medical waste <br /> transported offsite for treatment and disposal, including the quantity of the waste <br /> transported, the type of the waste transported, the date the waste was <br /> transported, the name of authorized person that transported the waste and the <br /> destination of the waste. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH $67 APPLICATION FEE TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> P.O. Box 388 <br /> Stockton, CA 95201-0388 <br /> Medical Waste Hauler Information <br /> Medical Office/Business Name: rAf 4LT h CSRE <br /> P_ <br /> Medical Office/Business Address: 1414&z: <br /> City: ::57Z) IcItA3 State:. CA Zip Code: 9s�o <br /> Contact Person: SAR-4 RA; , :6`P —Phone o2oq ) 4166 <br /> Permitted Treatment Facility Name:- 6F.&774 Wc_14L7-74 CARF_ Permit 00,25447' <br /> Permitted Treatment Facility Address: �/ fz /V. eet zta S7- E'[=T <br /> City: 5 Tor_lcm 40 State: CA Zip Code: 9.5,9o;Z <br /> Please list employee names and titles authorized to transport the medical waste. <br /> 1- Name: MIJPv 'be7A;,FaS —Time: A)P <br /> 2- Name: 1,; 64 Title: A)lf <br /> 3- Name: 5,qkA CzoDLuIA) Title: A) - 2) Zg. OF U1x)jC,4,e_ 5- R2jjjCx*S <br /> If transporting medical waste to a permitted storage facility for consolidation purposes or if veterinarian or <br /> home health care nurse transporting medical waste back to own facility, please complete the following: <br /> Storage Facility Name: —Permit <br /> Storage Facility Address: <br /> City: —State: Zip Code: <br /> A copy of this exemption and a tracking document containing the information above shall be in <br /> employees possession at all times while transporting medical waste. In addition, all copies of <br /> medical waste records shall be kept on file at your facility. <br /> 9 57,�;_XllDate:lc <br /> V <br /> Applicant Signature: 0_46LGOGA <br /> L� - Title:4,e ITr <br /> R.E.H.S. Application Approval:X�jAgr, Date: <br /> EH 45 02 09-27-95 <br />